Suspect dementia if you become aware from the patient or from their family or carer(s) of any of the following:

Onset is usually gradual

Memory problems

Disorientation

Change in personality

Loss of emotional control

Change in every day ability to function in their usual environment

Differential Diagnosis

The following can simulate dementia and need actively excluding:

Delirium (previously known as ‘toxic confusional state’) is generally a transient condition characterised by inttention or acute cognitive dysfunction of sudden or relatively sudden onset. If not recognised and treated appropriately, delirium can become a chronic condition.

20% of patients over 65 when hospitalised will suffer from some for of delerium during their stay.

Charles Bonnet syndrome (CBS) involves visual hallucinations due to eye disease, usually associated with a sharp decline in vision. Interesting features of the condition are the complexity of the hallucinations and the fact that there is some consistency between people in the types of images seen, most notably images of faces, children and wild animals. Please follow this link to further information on CBS.

In MCI there is subjective cognitive deficiency with no decrease in actual cognitive function. However:

60% of those diagnosed with MCI progress to dementia within 5 years and therefore need to be regularly reviewed

Alzheimer’s Disease

Key features:

50-70% of cases.

Gradual development often over years.

Common early symptoms of Alzheimer's include repetition, getting lost, difficulties keeping track of bills, problems with cooking especially new or complicated meals, forgetting to take medication, and word-finding problems. However, the essentials of personality tend to be retained.

The part of the brain most affected by Alzheimer's is the hippocampus. Other parts of the brain often also show atrophy, include the temporal and parietal lobes.

Vascular Dementia

Key features:

25% of cases.

Symptoms relate to the site of the stroke(s).

History of cardiovascular disease.

Tendency to develop in a stepwise fashion.

Brain scan may show evidence of multiple different strokes of different sizes in different sites.

Mixed Vascular and Alzheimers Dementia

CT scan shows features of both conditions.

Lewy Body Dementia

Key features:

15% of cases.

Relatively rapid progression.

Usually presents with associated > 6 months’ hallucinations and delusions and features of ‘Parkinsonism’ (tremor, rigidity, mask-like fascies).

Imaging may not be diagnostic, occipital hypoperfusion on SPECT scan or occipital hypometabolism on a PET scan are common findings.

Fronto-Temporal Dementia

Key features:

Typically presents with drastic personality change and language difficulty. Memory problems are not the main feature. Early social withdrawal and early lack of insight are characteristic.

Semantic (language) or temporal variant: difficulty naming things eventually progressing to losing the meaning of objects as well (e.g. unable to identify likenesses or differences).

Progressive non-fluent aphasia (PNFA): principally problem in speech production, with difficulty in finding the right words, and particularly difficulty in the orofacial coordination required to speak. May eventually, use single syllable words or even become mute.

Progressive Supra-Nuclear Palsy (PSNP)

Key features:

A rare neurodegenerative disease characterized by early loss of up and down eye movements.

Usually commences with a vertical gaze palsy. A loss of both up and down movement is almost pathognomonic). Other key symptoms include balance problems, falling backwards, rigidity, slow movements, irritability, apathy, social withdrawal and depression. Frontal lobe signs such as perseveration, a grasp reflex and ‘utilization behaviour’ (the need to use an object once seen). Progressive difficulty eating and swallowing and eventually with talking is also common.

Imaging often shows midbrain atrophy.

Picks Disease

Key features:

A rare form of fronto-temporal lobe atrophy causing dementia in often younger patients, often presenting in their 50’s.

Presents typically with dementia and aphasia. Behavioural changes may include efforts to dissociate from family, inappropriate anxiety, impaired regulation of social conduct (tactlessness, dis-inhibition, misperception), passivity, low motivation, inertia, over-activity, pacing and wandering. The changes in personality help distinguish it from Alzheimer's.

For more information about the Geriatric Depression Scale please see the Education topic button on the right.

The image of choice from within primary care is coronal section CT-Scan (see the CT page for available services and referral information). This will exclude intracranial mass lesions such as brain tumours and also normal presure hydrocephalus. Features consistent with various causes of dementia may include:

Alzheimer's: The principal focus of degeneration is the hippocampus. Other parts of the brain often also show atrophy, include the temporal and parietal lobes.

Vascular dementia: Multifocal infarcts of varying sizes in different sites,

Lewy Body disease: Routine imaging may not be diagnostic. However, sophisticated scans vcan be helpful: SPECT scanning may show occipital hypoperfusion and a PET scan may show occipital hypometabolism.

Diagnosis and initial management

GPs are encouraged to make the final diagnosis of dementia, with multiprofessional support if needed, but this is often not required.

Any decisions made should always be based on the best interests of the patient and GPs should ask the patient whether they think it is Dementia?

Who to Refer for Diagnosis and Initial Management

After initial workup, please refer the following to the Memory Assessment Service: ( For referral form see services and referrals section)

Young patients (e.g. under 65).

Uncertainty of diagnosis or the best course of action.

Complex cases.

Please ensure that any referral includes a detailed history, together with all relevant investigation and neuroimaging results. In the case of neuroimaging, please also indicate where the scan was performed.

Key Point

A multi- professional group within Gloucestershire (2015) considered that for patients with severe memory loss, a referral to the Memory Assessment Service offers no added value to the patient and may actually cause additional distress. However, a decision to diagnose and manage within primary care should be based on the best interests of the patient, and discussed with the patient and carers.

Ongoing Care

The advice below is consistent with the current Gloucestershire Joint Formulary (GJF) and their detailed prescribing sheets can be accessed through it:

Drug therapy has limited benefit in dementia and is frequently associated with paradoxical effects and can complicate an already difficult situation. However, although they should be used with care, drugs do have a definitive roll in the management of a number of problems.

Document that discussion to initiate drugs has taken place with carer, and where possible the patient.

To improve memory – Alzheimer’s disease only

They can help 40-70% of sufferers with a 6-12 month improvement in symptoms before decline sets in again. These patients can experience reduced anxiety, improved motivation, memory and concentration and an improved ability to cope with daily activities such as personal care, shopping and dressing. They are also felt to slow down disease progression to some extent.

They can be tried in patients with mixed picture Vascular/Alzheimer’s dementia.

Recommended by GJF

Donepezil – an anticholinesterase, prescribe only generically.

Avoid if pulse < 60. No need for ECG unless cardiac concern.

Common side effects: vivid dreams, diarrhoea.

Initiate at 5mg mane, on a trial basis.

If tolerated well, increase to 10mg after 4 weeks.

Continue more or less indefinitely, or until they are felt to be no longer of benefit.

Monitor at intervals.

Alternatives (GJF)

Galantamine – an anticholinesterase; originally Reminyl, but now available as a generic

Rivastigmine patches - an anticholinesterase; available as patches which may avoid some of the GI side effects or oral administration. Originally Exelon, but now also available as a generic.

Memantine – an NMDA receptor antagonist recommended (NICE) for severe Alzheimer’s disease or in moderate disease where AChE’s are poorly tolerated. In the middle and later stages of the disease it can slow down the progression of symptoms, including disorientation and difficulties carrying out daily activities. It may also help with symptoms such as delusions, aggression and agitation. Originally Ebixa, but now available generically.

Monitor the patients BP if on Memantine.

Managing Anxiety

Depression and additional pathologies should be specifically sought.

Anxiety should be tolerated to some extent and wherever possible be managed by non-pharmaceutical means.

Medication is associated with a high frequency of unwanted and sometimes serious side effects.

Antidepressants

Antidepressants are much safer than antipsychotics, often worth a trial of Mirtazepine or Trazodone

Benzodiazepines

Benzodiazepine use in elderly patients is associated with falls and cognitive impairment.

Lorazepam – preferably for short term use only. It is powerful, short acting, with little hangover effect but tolerance can develop quickly

Antipsychotics

When antipsychotics (phenothiazines or atypicals) are used in elderly people with dementia, there is a clear increased risk of stroke and a small increased risk of death (click here for MHRA advice).

Sedation, Parkinsonism and non-specific decline should be watched for.

Secondary care will initiate treatment and develop and agree a care plan, in most instances patients will be referred back to primary care for ongoing monitoring, with support from the Dementia Nurse and Advisor.

Once back in primary care, please review their care and ensure that no steps have been left out.

Once diagnosis is confirmed then consider treatment/further treatment

Social Prescribing (Community Resources) can be used to support patient and carers however it is best done through a Dementia Advisor who has the time and the knowledge to help the client)s to find the services they would like to make use of.

Agree/develop a care plan in association with your MDT

Ensure that monitoring arrangements are specified – by whom and how often.

Community Dementia Nurses should see the patient one month after initiation of any medication and will ensure that the patient is connected into any locally available post-diagnosis dementia support system.

Add to practice Dementia register

Adding the patient’s details to the Gloucestershire’s My Online Care Plan is a good idea to ensure that OOH services have access to key information.

Carer register and assessment

Managing Memory 2gether i.e the Dementia Advisor or/and the Community Dementia Nurse will give the patient a leaflet/booklet on Dementia

Supporting the process of diagnosing dementia.Initial post diagnosis support and care planning.

On completion of diagnostic pathway, the MAN will refer to CDN for ACI monitoring if on treatment, to the GP if the patient is not on treatment and is neither high risk nor has complex needs, or to CMHT (see below) if complex needs and/or high risk requires an MDT approach.

The CMHT (later life) sits in the wider CMHT in secondary care, and accept referrals of complex cases where a Multi-Disciplinary Team approach (access to Medics/OT/Physio) is deemed necessary.

Eg.:

Transition into care home

High Risk issues in the community

Complex Behavours that challenge

Care Home Support Team Mental Health Nurses

Non complex cases

Training/education/support

Behaviours that challenge in care homes

No official access to old age psychiatrist though closely linked and often joint working-not usually needing seperate referral from GP.

Elderly Care Consultant Psychiatry

No official access to old age psychiatrist though are able to access informal advice and share this with GP . Most frequently these are questions re medication.

Consultant psychiatrists are accessed through the Community Mental Health Teams.

The Dementia Adviser is a community worker skilled in assessing a patient needs and matching these to resources available in the community including a variety of clubs and services. The contract for these invaluable dementia support workers is currently with the Alzheimer’s Society. The Dementia Advisors maintain low level contact with clients and are well placed to signpost people to local services and community networks. They work closely with Managing Memory 2gether.